Every finding on record at Amary Comfort Care Inc.

Observed in Record Review. In 1 of 1 discharge records reviewed, the hospice surveyor noted that in the discharged chart reviewed no information was sent to the receiving facility. In review of DCRR#1 the patient daughter wanted to discontinue services. The organization did not send a discharge summary to the receiving facility that the patient was going to be staying in. This was discussed with the Director of Nursing and the Administrator.

Observed in Leadership Session. During review of EM plan and discussion with leadership and office staff it was noted that there was no documentation of any evaluation or critique of the exercises to identify opportunities for improvement.

Observed in Record Review. In 6 of 12 patient records reviewed, it was noted that the plan of care did not include measurable/timed goals. For example, in review of record for HV#1 the following goals were stated, Pt/Cg will verbalize a plan for preventing impaired skin integrity and acute confusion will be reduced to manageable level and Patient/caregiver will verbalize understanding of ordered medications including side effects, importance of taking medications as ordered, and effects to report immediately to health care provider. In record review for HV#2 the following is an example of a goal, Patient will have acute confusion/agitated behaviors reduced to manageable level within the limits of the disease. In HV#3, the following is an example of a goal, Patient/caregivers will verbalize understanding of changing ADL assistance needs with disease progression., however the patient has been bedbound for years with little to no change in ability to perform ADL's. Additionally for this patient, her primary issue is skin integrity in the perineal area however this problem is not identified on the plan of care. In record review #1 the following goal was stated: Caregivers will demonstrate safe and effective ADL care for patient needs. In record review #2 the following goal was stated: Caregivers will manage incontinence of bowel and/or bladder. This was discussed with the administrator.

Observed in Record Review. In 1 of 8 patient records reviewed, with hospice aide services it was noted in review of record for home visit #2 that the plan of care for aide frequencies was incorrect. For example, on the initial plan of care the aide frequency was stated as 3 week 14, 5 week 13. The intended frequency was 3 wk 1, 1 wk 13. This was discussed with administrator.

Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that in review of record for home visit #2 the plan of care did not include all pertinent information or diagnosis. For example, the only diagnosis was stated as Alzheimer's disease however during the patient visit the caregiver wife stated that the patient had COPD, Asthma and Emphysema during a bout of coughing observed during the visit, additionally the caregiver stated the patient used oxygen PRN however there were no orders for oxygen in the record. In another example, in review of record #2 it was noted that there were no orders wound care that was documented as performed by the nurse on her recertification assessment. In record review #2 and #6 the order for oxygen was incomplete and did not contain the frequency or route of delivery. This was discussed with the administrator.

Observed in Leadership Session. In review of QAPI plan and meeting minutes it was noted that the QAPI program did not focus on indicators that are related to improved palliative outcomes. For example, there was no data to support that palliative outcomes were identified or measured. In every area identified as criteria for review the following statement was noted, Continue to review the program quarterly as part of the QAPI program and report to the QAPI committee biannually and the Governing Body annually. There was no evidence that the reviews or audits were conducted for example, on any HR files, Pt. Satisfaction, Hospice Aide services, Counseling services, discharges or revocations or any Patient Quality Indicators. This was reviewed with all leadership and staff.

Observed in Document Review. During review of documents it was noted that the organization did not use data to monitor the effectiveness of the program or quality of the care. For example the infection data was inaccurate and not relevant and the occurrence data was also inaccurate. This was confirmed by the leadership.

Observed in Leadership Session. In review of QAPI plan and meeting minutes it was noted that the plan was not organization wide as evidenced by there being no data for the bereavement program, contracted services, DME, and Pharmacy or Volunteer services. This was discussed with the administrator.

Observed in Document Review. In review of infection data reported it was noted that the organization did not appropriately identify infections. For example, chronic constipation was reported as a bowel movement infection. All skin rashes were reported as infections, all wounds were reported as infections without cultures or any evidence of infection. This was discussed with the administrator.

Observed in Record Review. In 4 of 8 patient records reviewed, it was noted that in record review for home visit #2 the aide plan of care was not updated to include an increase in visit frequency from 3 to 5 times per week and did not accurately reflect the patient's ability to get up to the shower, etc., be transferred, etc as the patient was assessed to be bedbound at start of care. Additionally, the aide care plan indicated that the patient was to be on Standard precautions as well as droplet, contact and airborne precautions and that the diet was to be a regular diet. There was no order or indication for any infection control precautions for this patient and he was on a pureed diet. Lastly the patient was using oxygen on a PRN basis however oxygen precautions were not checked on the aide plan of care. In record review for home visit #3 the most recent aide care plan did not include any type of bath assignment and indicated that the patient was on a tube feeding. The aide was observed performing a bed bath and the patient did not have a g-tube or other tube feeding. In record review #3 it was noted that the aide plan of care for the most recert certification period did not contain a bath assignment. In review of record #5 it was noted that the RN did not complete an aide assignment prior to the aide services beginning. For example, the nurse prepared the aide care plan five days after the aide began providing care. Additionally, once completed the aide assignment was inaccurate and listed appliances, activities and bath that were inappropriate for this patient. This was discussed with the administrator.

Observed in Record Review. In 1 of 8 patient records reviewed, with aide services, it was noted that supervisory visits were not made every 14 days. For example, in the past three months there were three different instances, one 17 day period, one 27 day period and one 15 day period. This was discussed with the administrator.

Observed in HR File Review. In review of the only volunteer file it was noted that there was no documentation of any hospice volunteer training, no certificate etc.in the HR file. This was confirmed by the HR staff and discussed with the administrator.

Observed in Document Review. During discussion with leadership and volunteer coordinator, it was noted that there was no documentation of any recruitment activities over the past three years. This was discussed with the administrator.

Observed in Document Review. During document review and in discussion with leadership staff it was noted that there had been no estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions over the past three years.

Observed in Document Review. During review of documents and in discussion with leadership staff it was noted that there was no documentation available for the past three years to indicate that volunteer hours equaled or exceeded 5 percent of the total patient care hours of all paid hospice employees and contract staff.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.58, 418.76, 418.78, 418.100, 418.104.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the medical director competency was last completed in 2022. This was discussed with the administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that the certification of terminal illness on initial certification was a copy and paste of the admitting nurse narrative note to include receiving the patient on a stretcher and will meet with the wound care nurse on Thursday and did not include physician subjective or objective medical findings or any information about the medical management of the patient’s conditions unrelated to the terminal condition. This was discussed with the administrator.

Observed in Record Review. In 9 of 12 patient records reviewed, it was noted that the patient records were not maintained in accordance with the standards of practice. For example, in record reviews for HV #1. 2. 3 there were discrepancies in the plan of care, medication profile and frequencies. In DC record reviews #1 and #2 there were incomplete forms, undated forms, and documentation for supervisory visits where there was no aide ordered. In record review for home visit #3 specifically, the patient level of care was documented as continuous care however the patient was on routine care, documentation on the aide care plan stated that the patient had a tube feeding and lived in her home however the patient did not have a g-tube and lived in an ALF and the most current aide care plan did not include any bath assignment, however a complete bed bath visit was observed on survey day two. In record review #1 it was noted that the documentation indicated that the patient was on continuous care however the patient was receiving routine hospice care. In record review #3 there current aide plan of care did not indicate any bath type and therefore the aide notes did not indicate a bath was given however upon discussion with the aide it was noted that a bed bath is given each visit. In record review #4 it was noted that the recertification nursing assessment indicated that the patient was a male however the patient was female. it was noted in DC record review #2 that the RN documented supervisory visits for a specific hospice aide however there were no aide services being provided. In record review #5 it was noted that the aide plan of care indicated a shower was to be given, that the patient had an ostomy, that the patient used a hoyer lift, was able to use a bedpan and dangle at the bedside. None of these items were accurate for this bedbound patient following kyphoplasty surgery and with no ostomy. This was discussed with the director of nursing and administrator.

Observed in Record Review. In 3 of 8 patient records reviewed, records reviewed with hospice aide services it was noted that the hospice aide visit documentation was inaccurate. For example, in 3 of 3 aide notes reviewed for home visit #2 the documentation indicated that the following baths were performed during the visit; tub, shower, bed bath, chair bath indicated by a check mark in all areas. In review of record for home visit #3 review of 3 of 3 aide notes it was noted that the following baths were performed; bed, shower, chair. In record #5, in 3 of 3 aide notes reviewed indicated that the following baths were performed during the visit; tub, shower, bed bath, chair bath indicated by a check mark in all areas. This was reviewed with the alternate administrator/alt director of nursing. Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that for home visits #1 and #2 the record did not contain accurate medication reconciliation. For example, in record review for HV #1 it was noted that the medication profile stated Lorazepam 1 mg give 1 tablet every 4 hours PRN agitation however the bottle in the home stated Lorazepam 0.5 mg give 1 or 2 tablets every 2 hours PRN. Additionally, the medication profile stated Mirtazipine daily however the wife stated that this mediation was discontinued one month ago. In review of record for HV#2 it was noted that the patient was taking Zinc supplements and Iron supplements daily however neither was on the medication profile. Additionally the mediation profile indicate that the patient was taking Allopurinol however the wife stated that it had been discontinued a week or two ago. In home visit #3 it was noted that the medication profile stated Nystatin Cream was to be applied twice daily. The caregiver stated they did not have any creams to apply however they were using Nystat powder to the vaginal area and this was not on the medication sheet. This was discussed with the administrator and Director of Nursing.

Observed in Record Review. In 2 of 2 patient records reviewed, it was noted that in both discharged charts reviewed no information was sent to the receiving facility. In review of DCRR#1 the patient was transferred to another hospice per pt. request and no information was sent. In review of DCRR#2 the patient was transferred to the hospital following revocation however no information was sent to the receiving facility. This was discussed with the Director of Nursing.

Observed in Record Review. In 1 of 2 patient records reviewed, it was noted in record review for DC RR #2 that there was no documented discharge summary therefore it was not sent to the physician. This was discussed with the administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, it was noted in record review for DC RR #2 that the discharge summary was not a summary of the patient's stay including treatments, symptoms and pain management. The only documentation was a narrative statement of the diagnosis and comorbities and where the patient was transferred. In DCRR#1 it was noted that there was no discharge summary documented. This was discussed with the administrator.

Observed in Record Review. In 6 of 12 patient records reviewed, it was noted that in record reviews #1, 3, 4, 5 and 7 as well as record review for home visit #3 it was noted that there was documentation in the record of a form entitled No Primary Caregiver which indicated that the patient lived alone and had no primary caregiver however all of these patients lived with family members or private round the clock caregivers. The forms were all signed and dated by the patient or POA, the nurse and dated. This was discussed with the administrator and alternate director of nurses.

Observed in Document Review. In 1 of 6 contracts reviewed, it was noted that in review of the contract with Tallwood Home Medical Equipment the contract did not contain a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator,

Observed in Record Review. In 7 of 12 patient records reviewed, it was noted that documentation did not support the patient's right to informed decision making. For example in DCRR#2, the revocation form did not include any documentation of why the patient was revoking and although signed by the POA and nurse, it was not dated. Additionally in this record the ABN form was signed and dated at the start of care. In records for home visit #3 and record reviews #1, 2, 3, 4, and 5 the ABN form was filled in with reasons for discharge and signed and dated at the start of care. This was discussed with the administrator.

Observed in Record Review. In 7 of 9 patient records reviewed, The HCO did not ensure an initial or on-going comprehensive assessments were completed by the interdisciplinary team. As evidence by: On HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #6, RR #7, and RR #9, the surveyor noted there was no documentation that the initial and updated interdisciplinary team notes include psychosocial or spiritual care assessments. Regulations require a patient-specific comprehensive assessment be conducted and documented initially and updated as necessary on patients who elect to receive hospice care. These findings were reviewed, discussed, and validated by the Administrator/DPCS.

Observed in Record Review. In 8 of 9 patient records reviewed, The HCO did not ensure the initial social worker and chaplain assessment were completed within five days of the patient electing the hospice benefit. For example, the surveyor noted on patient HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #6, RR #7, RR #8 and RR #9, the registered nurse documented the patient refused the social worker and chaplain; however, there was no documentation that the registered nurse completed the psychosocial and spiritual care assessments and presented them to the interdisciplinary team for review. Standards require a comprehensive assessment, including psychosocial and spiritual care be completed within five days of a patient electing hospice care. These findings were reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 4 of 9 patient records reviewed, The HCO did not ensure patient care plan goals were attainable, measurable, relevant, specific, and individually timed. For example, the surveyor noted on HV #1/RR #1, HV #3/RR 3, RR #6, and RR #9, the patient’s care plan goals included goal statements such as patient’s physical and psychosocial needs to be met with assistance from the family and maintain balance in the patient’s “GI” system, Pt will not experience increased agitation for this cert period, Pt will be kept comfortable until her demise w/o evidence of discomfort, medication effectiveness in treating symptoms. Additionally, the care plan goals were not updated for the duration of the certification period. These stated goals are not realistic and do not contain information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to complete hand hygiene as required by the organization's policies. As evidenced by: on HV #3/RR #3, the hospice aide, after hand washing, neglected to use paper towels to turn off the water faucet, but touched the knobs with wet hands. The organization’s hand hygiene policy requires, when washing hands with soap and water, clean paper towels are used to dry hand, then turning off water with that paper towel. These findings were reviewed, discussed, and confirmed with the Administrator/DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, The HCO did not ensure the aide care plan specify duties specifics. For example, on HV #3/RR #3, the surveyor observed the hospice aide obtaining the patient’s vital signs. The aide care plan did not include instructions to obtain vital signs. Standards require a qualified person, responsible for supervision of the home health aide, provide written patient care instructions that specify aide duties. These findings were reviewed, discussed, and confirmed with the Administrator/DPCs.

Observed in Tracer Visit. The HCO did not ensure there were recruitment and retention efforts for its volunteer program. As evidence by: The surveyor noted there was no documentation or evidence of the organization conducting recruitment and retention activity for its volunteer program. Standards require such activities be documented. These findings were reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO’s staff did not follow the organization's bag technique policy. As evidenced by: On HV #3/RR #3, the surveyor observed hospice aide removing and replacing medical equipment in bag without establishing clean and dirty areas and leaving bag open while providing care. The organization's policy included that a clean and dirty area be established, and the bag be closed during the visit when not being accessed. These findings were reviewed, discussed, and confirmed with the Administrator/DPCs.